Abnormal Uterine Bleeding: Is It an Under-Reported Side Effect after Epidural Steroid Injection for the Management of Low Back Pain?

Abstract

We read Dr. Gitkind's report with great interest [1]. Since epidural steroid injection (ESI) is a rational treatment approach for radicular pain due to herniated nucleus pulposus and lumbar stenosis [2], its popularity is rising. It is reported to decrease surgical rates and self-reported pain and disability [3]. Corticosteroids contribute to pain treatment with their ability to decrease inflammation by inhibiting production of prostaglandins and excitation of c-fibers, which is mainly responsible for pain generation. However, ESI is not an option free of side effect due to intervention itself and the drugs used [4]. Here, we describe two patients with abnormal uterine bleeding following ESI.A 48-year-old premenopausal woman with low back pain due to L4-L5 lumbar stenosis was referred to a pain clinic. Her pain was assessed as 8 according to the numeric rating scale (NRS) for pain, where 0 represented "no pain" and 10 represented "the most severe pain." She received interlaminar epidural injection with lidocaine 1% and methylprednisolone 80 mg in a 10-mL solution at the L4-L5 level. Pain level was 5 after the injection. The patient complained of uterine bleeding lasting for 2 days beginning on the second day of injection.A 42-year-old premenopausal woman with low back pain due to L5-S1 stenosis presented to a pain clinic. Her pain was assessed as 7 by the NRS. She received caudal epidural injection with lidocaine 1% and methylprednisolone 80 mg in a 20-mL solution. Pain level was 2 after the injection. The patient complained of uterine bleeding starting on the fifth day after the injection and lasting for 3 days.The two patients did not have any other known endocrinologic disorder. However, both patients consulted with the gynecologist to exclude any other condition that may present with uterine bleeding or mimic this condition, and they were confirmed to have none of the related acute pathologies. They did not experience the symptoms again because we did not repeat the injections.The systemic side effects of epidurally administered corticosteroids include increase in blood glucose, some fluid retention, Cushingoid syndrome, and temporary adrenal suppression with an incidence of 2.2% [1]. Neuroaxial corticosteroids may also initiate a negative feedback loop both in hypothalamic-pituitary and hypothalamic-ovarian axes, resulting in decreased luteinizing and follicular stimulating hormones and lack of progesterone spike. These may contribute to uterine bleeding as a side effect of ESI. There is only one report about this side effect that describes similar symptoms in a premenopausal patient and relates the symptoms to the systemic effect of corticosteroids when administered epidurally [1]. Our patients were also premenopausal, and they reported this side effect presuming that it was associated with ESI. However, some premenopausal patients with uterine bleeding following ESI may remain unreported because they experience the bleeding during their normal menstrual cycle. Besides, in clinical practice, the patients ar...

An unusual cause of postmenopausal bleeding

“…A history similar to this was reported by Willey et al 4 in a study of comparison of oral prednisolone and intramuscular depot triamcinolone in patients with severe chronic asthma. Two other patients in the perimenopausal age group had similar episodes of vaginal bleeding after epidural steroid injection, as reported by Cok et al 5. This case report illustrates the rare side effect of this steroid medication, triamcinolone acetonide, in a postmenopausal woman, though such a history should not make the gynaecologist defer a thorough investigation for the vaginal bleeding.…”

Abnormal Uterine Bleeding Following Lumbar Epidural Corticosteroid Injections and Facet Medial Branch Blocks in Both Pre- and Postmenopausal Women: A Case Series: Table 1

“…described two cases, both premenopausal women who developed uterine bleeding lasting between 2 and 3 days, within 1 week following either interlaminar or caudal ESIs. In addition, neither patient had pre‐existing endocrinologic disorders or gynecologic bleeding disorders [12].…”

Abnormal uterine bleeding induced by glucocorticoid treatment for pemphigus

“…Among them, 6 cases were pre- and postmenopausal women who developed AUB after lumbar and sacral epidural injection of glucocorticoids to control neurological pain. 4 , 5 The other cases included allergic patients who developed AUB following the application of triamcinolone acetonide. 6…”

“… 4 - 7 Thus far, only few cases of AUB following glucocorticoid treatment have been reported; moreover, information on the treatment modality for pemphigus after the development of AUB is scarce. 4 - 6 Over the past 3 years, we have treated approximately 3000 pemphigus and 800 pemphigoid patients with glucocorticoids, and only 3 patients with pemphigus vulgaris (PV) developed AUB. At our clinic, the incidence of AUB following glucocorticoid treatment among pemphigus and pemphigoid patients is approximately 0.1% per year.…”